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Self-injuring behavior e.g., skin picking, head banging, biting ; Stereotypy behavior e.g., repetitive, nonpurposeful movement in persons with pervasive [autistic] spectrum disorders; rocking; hand flapping ; Aggression or destruction Cyclic--consider bipolar disorder and migraine headache syndrome Poor impulse control disorder--sudden, unexplained aggression that resolves as quickly as it develops Temporal lobe seizure--sudden, unexplained aggression that resolves as quickly as it develops; associated with a change in sensorium before, during, or after behavior outbursts Sleep disturbance may be a symptom of a mood disorder ; Hyperactivity e.g., autism, ADHD, akathisia if using neuroleptic drugs, side effect of phenobarbital ; Attention deficit e.g., ADHD, autism ; Repetitive behavior patterns e.g., becomes "stuck" in an activity, such as hand washing ; Obsessive-compulsive disorder--appears stuck in an activity; when redirected, goes back to previous activity and becomes stuck again Autism--becomes stuck in an activity; when redirected, goes to new activity and may become stuck in that Miscellaneous--talking aloud to themselves.

3. Many patient cohorts studies are not representative of the distribution of race, ethnic and cultural factors, and socio-economic status among the severely obese population. 4. There is lack of uniform standards for reporting results. Different criteria for success of the various interventions have been used 5. There are also difficulties involved in assessing indirect and opportunity costs because of lack of data and variation in costs between countries and health care systems. The variation of cost of interventions between countries and health care systems also limits comparability. Although the natural history of morbid obesity is unclear, according to the Sheffield School of Health and Related Research ScHARR ; , it is possible to use existing coronary heart disease and diabetes modelling techniques to create risk tables for obesity and morbid obesity in particular32. In so doing, it may be possible to identify patients with the greatest potential to benefit from surgery and define criteria for using very scarce resources. In assessing the relative cost-effectiveness of interventions, emphasis needs to be on identifying the most cost-effectiveness pathways or routes in an algorithm rather than specific interventions as these interventions form part of a continuum of care for morbid obesity. However this analysis is complex and it is unlikely that this work can be done under the framework of the Evidence-Based Commissioning Group contract. Funding will there need to be sought for such work. 6. Target weight and rate of weight loss for management of morbid obesity Many guidelines stress that the priority in obesity management should not be to return to ideal or normal weight but to modest realistic weight loss and weight maintenance. Most patients do not succeed to return to their ideal weight and repeated failure to achieve normal weight may amplify the patient's depression and lack of self-esteem. There is strong evidence that even modest weight loss such as 5-10 kg over one year substantially reduces mortality and risk factors in obese people. However there is little evidence that a person who is advised to lose 5-10 kg does better than if advised to lose say 30-40 kg. The most appropriate target weight loss is likely to vary with individual circumstances. It should vary with factors such as age, fitness, family history of diabetes or heart diseases and associated co-morbid conditions. Thus although there is need for target figure which can be achieved by most patients, there is also a need for flexibility to suite individual circumstances. There is consensus that a rate greater than 1 kg week is undesirable, since it is likely to cause excessive loss of lean tissue3. A weight loss of about 0.4-0.8 kg week 1-2 1b week ; therefore appears to be the most reasonable and realistic target.4. A draft algorithm for the management of morbid obesity is provided in the appendix, building on information from guidelines developed elsewhere4, 7, 10. The algorithm is a draft and should be used by clinicians as a framework to further develop and produce feasible guidelines for use at PCT, hospital trust or health authority level. Dr Emmanuel Fru Nsutebu SHO, Public Health Medicine and sinequan.

Clinician quarterly is published by neighborhood health plan and is distributed to primary care providers in the nhp network.
The Circular advises on the recommended preferred products for a number of currently prescribed branded medicinal products in both primary and secondary care sectors see Appendix 2 ; . Details of the Therapeutic Tendering initiative were outlined in a previous communication in July 2006 CPh4 06 ; and this opportunity is being taken to re-circulate the first phase Product Standardisation recommendations from that communication see Appendix 1 ; . 2. Disease Management Prescribing Guides and vibramycin!

Tennessee Medical Foundation Roland W. Gray, M.D. Jeanne Breard, R.N. Mail: 216 Centerview Drive, Suite 304 Brentwood, TN 37027-3226 Telephone: 615 ; 467-6411 Fax: 615 ; 467-6420 Website: e-tmf.
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